- Case Report
- Open Access
- Open Peer Review
Endovascular iliac vein reconstruction through an obstructive pelvic nodal recurrence of urothelial carcinoma
© The Author(s) 2018
- Received: 14 June 2018
- Accepted: 27 July 2018
- Published: 30 August 2018
Chronic venous occlusion is common particularly in cancer patient due to hypercoagulate state associated with venous compression. Treatment options include endovascular management with venoplasty and stenting. Recanalization can be challenging in patients with complete venous occlusion secondary to significant external compression by a mass.
We report a case of a 73-year-old man with a history of bladder and prostate cancer who presented with worsening right leg edema and pain due to deep venous thrombosis secondary to a retroperitoneal mass. Management was sharp recanalization, venoplasty and stenting.
Endovascular intervention of chronic venous occlusion is technically challenging and time consuming. Sharp venous recanalization is feasible and safe in patients who failed standard recanalization procedures. We present a case of cancer-related obstruction of the right iliac veins and acute thrombosis of the femoral vein with symptomatic lower limb swelling relieved by sharp recanalization through the tumor mass.
- Sharp recanalization
- Deep venous thrombosis
- Venous compression
- Endovenous intervention
Deep venous thrombosis (DVT) in cancer patients causes significant morbidity and affects the quality of life (Blom et al. 2005; Delis et al. 2004). Acute DVT can be attributed to hypercoagulable state, compression, or both (Blom et al. 2005). Percutaneous endovascular intervention with or without thrombolysis may be performed to improve symptoms in acute DVT (Maleux et al. 2016; Sullivan GJ et al. 2015; Neglén et al. 2007; Murphy et al. 2017). When the venous inflow or outflow is compromised due to external compression or intra-luminal stenosis, thrombolysis alone may not be effective and the recanalized veins can re-thrombose.
Chronic venous occlusions that cannot be crossed with standard wire and catheter combinations are technically challenging. Lesion crossing attempts fail in approximately 5–24% of the cases of long-standing peripheral occlusions (Raju and Neglén 2009; Raju 2013; Raju 2015; Criado et al. 1994). When standard catheter and guidewire techniques do not permit connection of two patent lumens, sharp recanalization might be an option (Honnef et al. 2005; Athreya et al. 2009; Farrell et al. 1999; Dou et al. 2016). We describe a case of cancer-related iliofemoral venous occlusion and secondary acute DVT causing painful lower limb swelling which was managed by percutaneous extravascular venous bypass through an encasing nodal tumor using sharp recanalization, after the failure of conventional techniques. While it is not recommended to routinely pass through tumor because of the theoretical risk of tumor seeding and bleeding, an exception was made here because the patient was suffering from severe symptoms and the goal of care was palliation.
A 73-year-old man with past medical history of stage IV bladder and prostate cancer, status post cystoprostatectomy with ileal conduit, left orchiectomy, and subsequent left radical nephrectomy (for recurrent left hydronephrosis and pyelonephritis), presented with worsening right leg edema and pain for 2–3 weeks which confined him to bedrest. On examination, there was severe pitting edema of the right leg associated with erythema and warmth.
The patient was subsequently turned supine. A wire was advanced through a right common femoral artery access into the lower aorta to provide a visual safeguard for preventing arterial injury during sharp venous recanalization. An 18 mm Atlas balloon (Bard, Murray Hill, NJ) placed through a right internal jugular access was inflated across the IVC/left common iliac vein confluence to provide a central target. A 10 French right femoral venous sheath was inserted and the metallic stiffening cannula/catheter combination from a Rösch-Uchida Transjugular Liver Access Set was advanced into the peripheral (caudal) segment of the right common iliac vein stump. The metal cannula was then progressively advanced towards the target balloon in the lower IVC. A 21-gauge Chiba needle was advanced through the cannula (Fig. 2b). The needle and a 0.018-in. guidewire were used to create a channel through the encasing tumor into the caudal segment of the IVC with one pass (Fig. 2c).
Lower extremity deep venous disease can be extremely debilitating for cancer patients (Blom et al. 2005; Delis et al. 2004). While more data is needed, preliminary results suggest that this population can obtain significant palliation from endovenous interventions such as thrombolysis, angioplasty, and stenting (Neglén et al. 2007; Murphy et al. 2017). Most lesions are readily crossed with standard guidewires and catheters. In select cases, when standard techniques fail, novel creation of venous flow through sharp recanalization technique as described above may be useful.
All authors (BT, AS, and SK) contributed significantly in manuscript preparation, writing, and review of manuscript. All authors read and approved the final manuscript.
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